Mid-Revenue Cycle Transformation

The mid-revenue cycle has been under-resourced.

When a revenue integrity (RI) program in a healthcare enterprise is appropriately designed and implemented, providers can expect a higher clean claim rate, coding compliance, proactive identification and resolution of claim issues, and improved financial results.

As Rose Dunn stated in her article “HIM’s (health information management’s) Roles in Revving up the Revenue Cycle,” (https://www.icd10monitor.com/him-s-role-in-revving-up-revenue-integrity), achieving revenue integrity is an important goal for all revenue cycle leaders. By striving for it, we concern ourselves with correcting those practices, systems, and processes that create erroneous charges. Our goal should be to claim only those charges for which we are entitled to compensation and those that are supported by documentation in our records. 

Achieving revenue integrity is an important goal for HIM professionals, recognized by the revenue cycle management (RCM) team. For some unknown reason, the mid-revenue cycle has traditionally been under-resourced. The front end and the back end of RCM initiatives traditionally have received all the attention and focus, by both healthcare executives as well as RCM vendors.

Hospital leaders are often concerned that their organizations’ clinical documentation and coding processes are vulnerable to errors that could result in lost or decreased revenue, according to a recent survey conducted by consulting firm and technology vendor BESLER in partnership with HIMSS Media to identify the greatest industry challenges and potential opportunities for revenue cycle improvement. They surveyed more than 100 leaders within finance, revenue cycle, reimbursement, and HIM departments at hospitals and acute-care facilities in October 2018.

Mid-revenue cycle management encompasses all the processes between patient access and the business office. Clinical documentation, clinical coding, charge capture, pre-bill reviews, audits, and other claim preparation processes occur here.

The BESLER/HIMSS survey results (released in February 2019) showed that 84 percent of respondents believe that clinical documentation and coding carry high or medium revenue cycle risk, yet hospitals and health systems face significant obstacles in improving their mid-revenue cycle processes, including coding and documentation. 

2019 appears to be a time that the mid-cycle of RCM is attracting more attention and recognition, but there are still obstacles to overcome. Core to the mid-revenue cycle is the management of inpatient and ambulatory clinical documentation improvement and coding. Chief among the associated challenges is a lack of budget. Nearly half of surveyed hospital leaders (49 percent) said budget constraints prevented their organization from improving DRG coding and documentation, creating missed improvement opportunities in the mid-revenue cycle.

The revenue cycle is traditionally broken into the front and back ends. The good news is that a new market report shows providers are still looking to bolster the middle of their revenue cycles. According to the Markets and Markets report, the mid-revenue cycle management and clinical documentation market are projected to reach $4.5 billion by 2023, growing at a compound annual growth rate (CAGR) of 7.9 percent.

We are in the midst of a mid-cycle transformation! The time is now to bring your expertise to the executive table and explain the components and benefits of each step of the mid-cycle. The only way to justify your critical investment in resources such as technology and resources is to demonstrate ROI. In BESLER/HIMSS survey, 48 percent of respondents said difficulty proving ROI stopped their organization from executing DRG optimization efforts. HIM professionals must prove the ROI and articulate the value proposition.

Other obstacles cited in the survey results for improving the mid-revenue cycle included the following:

• Competing projects (45 percent)
• Lack of staff/headcount to manage improvement efforts (38 percent)
• Lack of familiarly with solutions to address challenges (34 percent)
• Existing solutions already widely entrenched or accepted (32 percent)
• Overcoming internal perceptions that there is no need for improvement (30 percent)

So, the time is now for HIM professionals to differentiate themselves as the mid-revenue cycle subject matter experts. Bring joy to the workplace and demonstrate to the industry that the sweet spot of the HIM profession is the mid-cycle!

Program Note:

Listen to Bonnie Cassidy report this story live today during Talk Ten Tuesday, 10-10:30 a.m. ET